period of the labour when the exhibition of chloroform should commence;
for, in proportion as the pains are feeble, it must be more sparingly
administered. The most usual time when the accoucheur and I have
determined that the inhalation should be commenced, has been when the os
uteri was nearly dilated to its full extent, and the pains were taking
on an expulsive character. In many of the cases which I have attended,
it has, however, been commenced much earlier; for the suffering caused
by the dilating pains in the first stage of labour is often very great,
and the chloroform is consequently of the utmost service when employed
at this time.
As regards the manner of giving chloroform, I shall first allude to
cases not requiring manual or instrumental assistance. In such cases,
when it has been determined to resort to inhalation, the moment to begin
is at the commencement of a pain; and the chloroform should be
intermitted when the uterine contraction subsides, or sooner, if the
patient is relieved of her suffering. It is desirable to give the
chloroform very gently at first, increasing the quantity a little with
each pain, if the patient is not relieved. The practitioner easily
finds, with a little attention, the quantity of vapour which it is
desirable to give at any stage of the labour, and in each particular
case; his object being to relieve the patient without diminishing the
strength of the uterine contractions and the auxiliary action of the
respiratory muscles, or with diminishing it as little as possible. At
first, it is generally necessary to repeat the chloroform at the
beginning of each “pain”; but, after a little time, it commonly happens
that sufficient effect has been produced to get the patient over one or
two uterine contractions without suffering, before it is resumed.
The external evidences of the uterine contractions continue as before,
when the patient is rendered unconscious by chloroform; and the muscles
of respiration are called freely into play, to assist the action of the
uterus in the second stage of labour. The aspect of the patient under
these circumstances, is generally that of one who is suppressing the
expression of her sufferings; and any relative or friend who comes in,
without knowing that chloroform has been given, begins to praise the
unconscious patient for her fortitude. On some occasions, indeed, there
are groans and cries, as of suffering; but the mind being unconscious of
pain, it can hardly be said to exist.
It may be remarked, that complete anæsthesia is never induced in
midwifery, unless in some cases of operative delivery. The diminution of
common sensibility to a certain extent, together with the diminution or
removal of consciousness, suffice to prevent the suffering of the
patient during labour; and she never requires to be rendered so
insensible as in a surgical operation, when the knife may be used
without causing a flinch or a cry. The nerves of common sensation must
be allowed to retain their functions to a certain extent during labour;
otherwise the assistance of the respiratory muscles, which consists of
reflex action, or “motion arising from sensation, without the aid of
volition”, would not take place, even if the contractions of the uterus
should still continue.
The effects of chloroform on the brain should not be carried during
labour beyond what I denominate the second degree of narcotism, or that
condition in which the mental functions are diminished, but not
altogether suspended, except when the effect of the vapour is associated
with natural sleep. The patient under the influence of chloroform to
this extent, has no longer a correct consciousness of where she is, and
what is occurring around her, but is capable of being aroused to give
incoherent answers, if injudiciously questioned. In this state, the
patient will sometimes assist the labour by bearing down voluntarily, if
requested to do so, and be otherwise obedient to what is said; and by
withholding the chloroform for a few minutes, she at any time becomes
quite conscious. As a general rule, it is desirable not to hold any
conversation whilst the patient is taking chloroform, in order that her
mind may not be excited. The plan mentioned above, of giving the
chloroform very gently at first, also has a tendency to prevent its
causing mental excitement, the patient coming gradually under its
effects. In surgical operations, excitement of the mind can nearly
always be avoided by carrying the patient pretty rapidly into a state of
insensibility, in which the mental functions are necessarily suspended.
But in the practice of midwifery, it is not allowable to cause a state
of coma or insensibility, except in certain cases of operative delivery,
hereafter to be mentioned.
I nearly always employ, in obstetric cases, the inhaler that I use in
surgical operations. There is not the same necessity for an accurate
means of regulating the proportion of vapour in the air which the
patient is breathing during labour, where but a trifling amount of
narcotism requires to be induced, as in surgical operations, where a
deeper effect is necessary; still I find the inhaler much more
convenient of application than a handkerchief, and it contains a supply
of chloroform which lasts for some time, thereby saving the trouble of
constantly pouring out more. When I do administer chloroform on a
handkerchief during parturition, I follow the plan of putting only ten
or fifteen minims of chloroform on the handkerchief at one time.
The quantity of chloroform administered during any one pain, never
exceeds a very few minims; but the quantity used in the course of a
protracted labour is often considerable. I have several times used from
four to six ounces; and in one case, at which I was present the greater
part of the time, seventeen fluid ounces of chloroform were used with
the inhaler, which would produce as much effect as three or four pounds
used on a handkerchief. The inhalation was continued with intermissions
over a period of thirty-one hours. The patient was unconscious during
the greater part of the last five or six hours, but previously to this,
her constant complaint was that she had not enough chloroform. She was
the wife of a physician, was thirty-seven years of age, and in her first
confinement. The membranes ruptured early. The labour was natural, but
there was excessive sensibility. The first twenty-six hours of
intermitted inhalation were during the first stage of labour.
Chloroform can be best applied when there is an additional medical man,
who has not to attend to the ordinary duties of the accoucheur; but it
can be given very well by the accoucheur himself, so as to save the
greater part of the suffering of labour; although he perhaps cannot
always administer it in the perfect way in which he could, if he had no
other duties to divide his attention.
It is probable that the use of chloroform has no particular influence
over the duration of labour, in the whole number of cases in which it is
employed; but individual labours are occasionally either retarded or
quickened by it, according to circumstances. In some cases, the
chloroform, even when very moderately employed, diminishes both the
strength and the duration of the uterine contractions, and prolongs the
interval between them, thereby making the labour somewhat longer—a
matter of no consequence, however, as the patient is not suffering in
any way. In other cases, the inhalation causes the uterine action to
become stronger and more regular, by removing the excess of sensibility
by which it has been interfered with. This occurs more particularly in
the first stage of labour. In some cases, also, the chloroform seems to
act as a direct stimulant to the uterine contractions, increasing their
force and frequency—a circumstance at which we need not be surprised,
when we remember that both opium and brandy, in moderate quantity, often
act in the same manner. Chloroform has also the effect of promoting the
dilatation of the os uteri in many cases, even when no rigidity exists;
and when there is rigidity of the os uteri, the inhalation is of the
utmost service, and shortens labour very much. This is the case, also,
when there is rigidity of the perineum.
When the forceps have to be applied, it is desirable to make the patient
insensible, as if for a surgical operation just before they are applied;
and to leave off the chloroform as soon as they are introduced, in order
to allow of the uterine action to return, and assist in the delivery. I
have always found the action of the uterus return immediately after the
forceps were introduced; and where the child was not delivered at once,
I have continued the chloroform in sufficient quantity to keep the
patient unconscious, whilst allowing the uterine contractions to
continue.
I have administered chloroform on nine occasions in which the forceps
were applied; in four of the cases, I was sent for in consequence of the
operation being required; and in the other five cases, I was in
attendance from an early part of the labour, and had administered
chloroform more or less for some hours before the forceps were applied.
They were applied in three instances by Dr. Murphy, twice by Dr.
Ramsbotham, and in the other cases by Drs. Farre, Frere, and Thudichum,
and Mr. Peter Marshall.
I have administered chloroform in two cases of craniotomy, both of which
were performed by Dr. Murphy, on account of deformity of the pelvis. The
amount of chloroform scarcely requires to be increased during this
operation beyond what would be given according to the strength of the
pains which may be present at the time.
In the operation of turning the child, the mother requires to be made
quite insensible, in order that the uterine contraction may be entirely
suspended till the legs of the child are brought down, when the
inhalation should be discontinued to allow the contraction of the uterus
to return. I have notes of six cases of turning the child, in which I
have administered chloroform. The first case, which occurred in 1848,
was one of natural presentation, in which turning was performed by Dr.
Murphy, on account of narrowness of the pelvis, and the impossibility of
applying the forceps; the introduction of the hand was difficult on
account of want of space, but the uterus offered no resistance. Dr.
Murphy has related the case. Three of the other instances of turning
were performed by Mr. French, in cases which had been attended by
midwives, and the membranes had been ruptured for several hours. The
shoulder and part of the chest were in each case pressed down into the
pelvis, and the pains were very strong; yet under a full chirurgical
dose of chloroform, the child was turned as easily as if the membranes
had not been ruptured. In the first of these three cases, the child was
dead before the operation commenced. In the other two, it was born
alive. In the last case, the membranes had been ruptured for ten hours
before the operation was performed. After the child was delivered, there
was found to be a second child presenting naturally, but I did not stay
to give any more chloroform. The fifth case of turning was performed in
a case of elbow presentation by Mr. Peter Marshall. The membranes had
been previously ruptured. I administered chloroform, also for Mr.
Marshall, in a case where the hand was presenting below the head; he
raised it above the head, and as it did not come down again when the
pains returned, the labour was allowed to pursue its natural course, and
terminated favourably in two or three hours, the child being alive. The
chloroform was not continued after the operation was performed. The
remaining case of turning was performed by Mr. Tegart, of Jermyn Street.
I was in attendance with him from an early stage in the labour, and the
operation was performed before the membranes were ruptured.
I administered chloroform, in 1849, in a case in which Dr. Murphy had to
make an artificial os uteri. The patient was, of course, made quite
insensible as for any other surgical operation; and the vapour was
continued afterwards in a modified degree till the labour was completed.
On December 26th, 1850, I was requested by Mr. Cooper, of Moor Street,
Soho, to assist him in a case of retention of the placenta. The patient
had given birth to a child two hours before, and Mr. Cooper had
introduced his hand, but had been unable to bring away the placenta, on
account of firm contraction of the uterus in a sort of hour-glass form.
On the chloroform being administered, the hand was easily introduced,
and the placenta detached, and extracted. There was very little
hæmorrhage.
In some of the many cases at which I have met Dr. Cape, premature labour
was induced about the eighth month of utero-gestation, by rupturing the
membranes, on account of deformity of the pelvis.
In a case attended by Mr. Cantis, the patient was suffering from
osteo-sarcoma of the bones about the shoulder. Dr. Ferguson was present
during the latter part of the labour. The lady lived a few weeks after
her confinement.
A patient, attended in her confinement by Mr. Colambell of Lambeth, in
1853, to whom I gave chloroform, had been long under the care of Dr.
Williams with cavities in the lungs. I heard very lately that she was
still living.
A patient of Mr. Robert Dunn, to whom I gave chloroform in her
confinement, was at the time in a state of insanity.
In one of the patients whom I have attended with Dr. Arthur Farre, there
was separation of the recti muscles of the abdomen; which there is no
doubt must have taken place gradually during pregnancy. The patient was
but twenty years of age, and in her first labour. Quite early in the
labour, before the pains were at all strong, Dr. Farre and I observed
that the abdomen was of a peculiar form, the uterus projecting very much
forwards, whilst there was a slackness in the flanks. The abdominal
muscles did not assist the pains at all; and it was probably from this
cause that the labour progressed slowly and was terminated at last with
the forceps. The recti muscles recovered their position by careful
bandaging.
The chloroform has always been left off as soon as the child was born,
but a little has been administered again on several occasions during the
expulsion of the placenta. The placenta has generally been expelled very
soon in the labours in which I have given chloroform; usually in about
five minutes. There has hardly ever been uterine hæmorrhage of any
amount, except in patients who had suffered from it in previous labours.
In a case attended by Mr. Nathaniel Ward, however, there was a slight
hæmorrhage before the birth of the child, and about an hour afterwards
there was a considerable hæmorrhage which made the patient feel rather
faint for some hours. She afterwards went on favourably, however. She
was a young woman who had had several children.
A patient, to whom I was recommended by Sir John Forbes, inhaled
chloroform in three confinements. She recovered favourably from the two
first; but on the third occasion, after going on favourably till the
fifth day, she was attacked with puerperal fever, and died on the
seventh day from her confinement.
I am not aware that more than one death has been recorded as having
occurred from chloroform during labour; and this took place in England,
in 1855, when no medical man was present.[151] The patient had inhaled
chloroform in America in a previous labour; but her medical man, on the
last occasion, who was her particular friend, forbad that agent, and
said that if she was determined to have it, he would not attend her. She
procured chloroform unknown to him, and a number of scents to put on her
handkerchief and hide the odour of it from him. He went to bed in the
house, and was not called up till his patient had been dead about an
hour. The monthly nurse, who had procured the chloroform for the
patient, said that she snored very loudly for an hour after she fell
asleep. About five drachms of chloroform were used from the bottle, and
the handkerchief from which it was inhaled remained close to the
patient’s face till she died. The death seemed to have taken place very
slowly, and the monthly nurse was extremely stupid to allow the patient
to die. It may also be remarked that the accident would not have taken
place except for the medical man’s extreme objection to the use of
chloroform.
The chloroform has been occasionally blamed by the friends of patients,
or medical men opposed to its use, in cases where patients have died
from puerperal convulsions or other causes, so long after the vapour had
been left off that it could not be the cause of death. The following
case shows how easy it would be to make a mistake with respect to the
effects of chloroform. Soon after its introduction, I was requested to
administer it to the wife of a medical man who had a great desire for it
in her confinement. Mr. Propert was to attend the lady. I was sent for
late one evening, but as there were no pains at the time when I arrived,
I was requested to go to bed in the house. After a time, I was called by
a servant, who told me that the baby was born, and that Mr. Propert was
sent for. I found that the birth had been so sudden that the husband,
who was in the room, could not get to the bed side before the child was
born. Mr. Propert arrived, and I went home, leaving the patient very
well. Mr. Propert informed me, that after I left the patient went into
such a state of syncope as to make him think she was going to die, and
continued so for some time. She ultimately recovered. There was no
hæmorrhage or any other cause to account for the faintness, and I
understood Mr. Propert to say, that if the patient had inhaled
chloroform, he should have blamed it for the condition into which she
lapsed.
THE INHALATION OF CHLOROFORM IN MEDICAL CASES.
_Neuralgia._ When the pain of neuralgia is not extremely severe, it may
be removed by the inhalation of chloroform without causing
unconsciousness; but when it is very severe, it is necessary to make the
patient unconscious before the pain is suspended. In some cases of
neuralgia of the face, the pain is so severe that the signs of it remain
after the patient is rendered unconscious, and only disappear when he is
quite insensible; and then, as the insensibility passes off, the hand is
raised to the face, and the contortions of the features return before
the patient awakes to be aware of his suffering. When the mental branch
of the fifth nerve is affected, the paroxysms of pain are accompanied by
a motion and smacking of the lips. In a hospital patient I have seen
this when he was awake, but in a gentleman only when his consciousness
was removed by the chloroform, and before complete insensibility was
induced; when awake, he restrained the impulse to this kind of motion of
the lips.
In administering chloroform it is desirable to continue it steadily and
gradually till the pain is relieved; and if the patient is rendered
unconscious before the pain is removed, to continue it till all signs of
suffering disappear. After the first inhalation of the vapour, the pain
will generally return in a few minutes, but when again subdued, it will
not return so quickly; and after it has been suspended a few times by
the repetition of the chloroform during the space of an hour or so, the
pain is usually removed either permanently or for two or three hours. In
some cases I have had to repeat the chloroform occasionally throughout
the day, and, on one or two occasions, for two or three days in
succession. The chloroform can, in general, only be considered a
temporary remedy, and therefore such other medicines should be applied
as may be thought advisable.
When I have prescribed chloroform in a liniment, to be applied to the
face, the patient has often found out that he obtained more relief by
smelling at the liniment than by applying it. Chloroform generally gives
great relief, however, when applied locally in neuralgia, either alone
or mixed with camphorated spirit; it is advisable to apply it on a piece
of lint or blotting paper, which should be covered over with tinfoil, or
some other impermeable substance, to prevent the evaporation. It causes
about as much heat and uneasiness as a mustard poultice, before it
relieves the pain.
_Spasmodic Asthma._ On November 12th, 1850, I administered chloroform in
the Hospital for Consumption, at Brompton, to a married woman, aged
thirty-five, a patient of Dr. Cursham. She was in a fit of spasmodic
asthma, but was the subject also of chronic bronchitis. Twenty minims of
chloroform were inhaled from an inhaler. It gave immediate relief,
producing a momentary state of unconsciousness, or a state bordering on
it. In a few minutes the difficulty of breathing gradually returned, but
not to the same extent, and the inhalation was repeated with a like
effect. The difficulty of breathing returned less quickly and severely;
and after a third inhalation of twenty minims she was completely
relieved, and could lie down. The patient had a good night, and was
better next day. On the 14th, she had another fit of spasmodic asthma,
which was relieved completely by the chloroform in the same manner as
the previous one. This patient inhaled extract of stramonium every
evening, by a method which will be described further on.
Other cases of spasmodic asthma have been relieved as readily and
completely; but in one or two cases, in which the difficulty of
breathing seemed to depend on disease of the heart, the relief was not
so great; the patient went to sleep, but the breathing remained
embarrassed.
_Spasmodic Croup._ I have administered chloroform in seven cases of this
complaint. It was recommended in every instance by Dr. Ferguson, and all
the cases ended in recovery. The children were from eight months to two
years of age; the majority being about a year. I always gave enough
chloroform to cause a state of unconsciousness, for which a few minims
suffices in a young child, and when the effect passed off, or nearly so,
I repeated the dose. I generally gave five or six doses in the course of
about half an hour, after which the child would often sleep for two or
three hours. In the milder cases it was repeated once a day; but in the
more severe cases it was continued, in the above manner, twice a day. I
administered it to a patient of Dr. Van Oven, respecting whom Dr.
Ferguson had been consulted, for fifteen days, twice every day,
excepting the last three days. This child was very ill when the
treatment was first commenced, having a severe fit of spasmodic
breathing every five minutes. When the chloroform is given during the
spasm, it is desirable to give it very cautiously.
Mr. W. J. H. Cox read a paper on the treatment of laryngismus stridulus,
with chloroform, at the London Medical Society, in 1850. He had
entrusted the administration of it to the mother or nurse, and directed
it to be given whenever the spasmodic breathing should come on. I am
inclined to think that this would be the best way of giving it, if one
could be quite sure of the intelligence of the party to whom it was
entrusted.
_Hooping-Cough._ I have only administered chloroform in two cases of
this complaint. It was recommended in both cases by Dr. Ferguson. One of
the children was extremely ill of bronchitis, and it died. The other
child recovered, but the chloroform was not continued. I am not aware
that chloroform has had any fair trial in hooping-cough. It should be
given whenever a fit of coughing comes on.
_Infantile Convulsions._ I have administered chloroform in two cases of
this disease, with the effect of relieving the convulsions, but the
children died. They were both extremely ill before the chloroform was
administered. One was the patient of Mr. Walter Bryant, and Dr. Seth
Thompson was consulted about it. A case has been related by Dr. Simpson
of Edinburgh, in which the chloroform was continued for a day or two,
and in which the infant recovered.